B. DENTAL BENEFITS (APPLICABLE TO ALL MEMBERS AND DEPENDENTS)
1. Delta Dental Program.
Dental benefits are provided under contract with the
Delta Dental Plan (“Delta Dental”) to all Active and Retiree members and Dependents. For participants and Dependents eligible for Retiree coverage under the terms of the Plan, the Delta Dental Preferred Option (“DPO”) applies as of January 1, 2005. Retirees who choose a DPO dentist will be reimbursed at a higher level than if services were performed elsewhere.
To use this program, members may make an appointment with any dentist of their choice from the Delta Dental list of dentists. All Delta Dental dentists will have Delta Dental treatment forms in their offices and will complete and submit them to Delta Dental for reimbursement. A complete list of Delta Dental dentists may be obtained by calling (800) 427-2737 or www.deltadentalca.org.
2. Schedule of Dental Benefits.
The following is a brief summary of the benefits
that are available through this program and is provided for information only.
% of Delta Dental Fee Schedule |
(Delta Preferred Option - DPO) |
Wiremen or Early Retirees
|
Motor Shop and Retiree Rates |
(Pre-Age 62) |
In-Network |
Out-of-Network |
Diagnostic & Preventive Benefit
(oral exams, cleaning, x-rays) |
100% |
100% |
80% |
Basic Benefits (Oral Surgery,
Restorative treatment, Root
Canals, Gum Treatment
Ondontics, Periodontics)
|
80% |
80% |
80% |
| Crowns, Jackets & other Cast
Restorations |
80% |
80% |
60% |
| Prosthodontic Benefits |
80% |
80% |
60% |
(Bridges, Partial Denture,
Full Dental) Annual Maximum: |
$4000 |
--- |
--- |
| Orthodontic Benefits |
80% |
80% |
80% |
| Maximum Orthodontics |
$4000 |
$1500 |
$1500 |
| |
|
|
|
| Delta Group # Active 4874-0005 |
Delta Group # Active 4874-0006 |
| Delta Group # Retiree 4874-0015 |
Delta Group # Retiree 4874-0016 |
The “DeltaPremier” Dental Plan for Actives and their Dependents and the DPO Plan for Retirees and their Dependents are administered by Delta Dental of California. If you have specific questions regarding benefit structure, limitations or exclusions, consult the Evidence of Coverage or contact Delta's Service Department.
3. Services that are NOT covered by Delta Dental.
Although your Plan covers many of the most commonly needed services, some services are not covered. If you are unsure whether a particular procedure is covered, or how much of it is paid for by your Plan, check with Delta Dental before proceeding.
The following are not covered by Delta Dental:
- Services for injuries or conditions that are covered under Workers’ Compensation or Employer’s Liability Laws;
- Cosmetic surgery or dentistry or services to correct congenital malformation;
- Experimental procedures;
- Therapeutic drugs, premedication or pain relievers;
- Hospital costs or extra charges for Hospital treatment;
- Anesthesia (except for general anesthesia for oral surgery);
- Extra-oral grafts, implants and implant removal;
- Treatment related to the Temporomandibular Joint (“TMJ”);
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